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What should one do to live to 100?
What do we do differently since many will live to 100?
Albert L. Siu, MD
Ellen and Howard Katz Chair
Professor and Chairman
Brookdale Department of Geriatrics
Mount Sinai School of Medicine
Financial Disclosure
Dr. Siu is an employee of academic medical center, and he is a Medicare participating physician.
Dr. Siu is on the Board of Directors of the Visiting Nurse of New York Dr. Siu is on the Board of Directors of the Visiting Nurse of New York and of VNS Choice which operates a Medicare Advantage plan.
Overview
Sustained improvement in longevity
Explanations for longevity improvement
Lessons for sustaining longevityLessons for sustaining longevity
Societal response to longevity
Decline in Disability in the U.S. Population Above 65, 1982-99
20
25
30
0
5
10
15
20
%
1982 1989 1994 1999
Total disabled, %
20
25
30
35
0
1
Prevalence of Multiple Chronic Conditions in Medicare Beneficiaries
No. of Chronic Diseases
0
5
10
15
1997 1998 1999 2000 2001 2002 2003
1
2
3
4+
Chronic diseases, %
(95%CI)
Hypertension
Heart conditions
Diabetes
59.7
31.4
19.3
52.5
30.7
15.2
60.5
31.9
19.3
65.0
31.6
22.7
<0.001
0.20
<0.001
Table 1. Descriptive statistics of adults aged 65 and over in the Health and Retirement Study (HRS) in 1998, 2004 and 2008.
Diabetes
Cancer
Chronic lung disease
Arthritis
19.3
17.4
11.6
65.5
15.2
14.6
10.8
59.1
19.3
18.1
11.6
67.7
22.7
19.1
12.3
68.8
<0.001
<0.001
0.01
<0.001
26.923.1 21.2
29.430.2 29.7
1922.7 23.9
11.6 15.2 17.4
20%
40%
60%
80%
100%
U.S
. Old
er A
du
lts,
%
13.1 8.8 7.8
21.2
0%
20%
1998 2004 2008
Year
U.S
. Old
er A
du
lts,
%
0 1 2 3 4+ diseases
26.3 25.3 25.4
19.217.4 18.417.8 17.7 16.6
5
10
15
20
25
30
U.S
. O
lder
Ad
ult
s, %
0
1998 2004 2008
Year
U.S
. O
lder
Ad
ult
s, %
ADL/IADL disability ADL disability
IADL disability
How have longevity improvements come about?
Occurrence of improvements over span of 150 plus years argues against a single specific medical or public health intervention
Improvements probably due to combination of Improvements probably due to combination of prosperity, education, and access to improved medical care
Prosperity has led to investment in biomedical advances and medical care, and education has led to wiser health and medical choices
What should one do to live to 100?
“Stay the course” by continuing to do what has brought about striking sustained improvements in longevity in Western nations
• Biomedical research and translation to speed discovery to bedside
• Education with a renewed focus on health literacy
Take advantage of opportunity to address “new” challenges in health care delivery
• “Manage” biomedical knowledge, disseminating information, and messaging to affect health behaviours
• Improve quality of care by striving to improve use of effective care while reducing interventions that are known to be ineffective
What should one do to live to 100?Adapting caloric restriction
Protein restriction• Inconsistent results in animal studies restricting dietary
protein, tryptophan, or methionine
Intermittent fasting• A few human studies show short-term benefits (e.g.,
pulmonary function or insulin sensitivity) of 30-50% caloric restriction for 2-3 weeks
• But “weight cycling” may increase mortality
What should one do to live to 100?Pharmacologic alternatives to caloric restriction -1
Activators of sirtuins (a family of proteins thought to modulate cellular energy status)
• Resveratrol (a polyphenol found in red wine) increases longevity in short-lived organisms (e.g., yeast) and delays longevity in short-lived organisms (e.g., yeast) and delays aging-related problems (e.g., cognitive performance) in mice.
• Human studies have focused on potential to mitigate negative effects of poor health habits, but convincing evidence of effects in humans is lacking
• Synthetic sirtuin activators developed and being tested
What should one do to live to 100?Pharmacologic alternatives to caloric restriction -2
Antioxidants• Therapies based on theory that aging process is driven by highly
reactive by-products of cellular metabolism
• Meta-analyses of studies have shown no health benefits from supplementation with vitamins A, C, or E or beta-carotene
Agents acting on glucose and insulin homeostatis• Therapies based on finding that aging is associated with insulin
resistance and decreased glucose tolerance
• 2-deoxy-D-glucose can mimic some of the benefits observed with caloric restriction but it is cardiotoxic
• Metformin mimics some benefits of caloric restriction (in gene expression and increased insulin sensitivity) but more studies needed on effects on lifespan
What should one do to live to 100?Pharmacologic alternatives to caloric restriction -3
Reducing advanced glycation end products (AGEs)• Therapies based on finding that glycosylated proteins found in aging
tissues
• Reducing dietary AGEs extend lifespan in mice and improve aging-related biomarkers in patients with diabetes
• AGE inhibitors (e.g., aminoguanidine) have shown vascular and immune benefits in mice, but drugs are poorly tolerated in humans
Agents acting on mTOR signaling pathway• Therapies based on manipulating pathways sensing cellular energy and
nutrient levels
• Rapamycin inhibit mTOR and may be useful in some neuro-degenerative conditions and cancer but effects on lifespan unknown
What do we do differently since many will live to 100?
The Legislative Remedy
“The program could be brought into actuarial balance over the next 75 years by an immediate 122 percent increase in the payroll tax (from 2.9 percent to 6.44 percent),or an immediate 51 percent reduction in program outlays or 51 percent reduction in program outlays or some combination of the two.”
2008 Report of Social Security and Medicare Board of Trustees
Chronic Disease Prevalence and Annual Costs
No. of Chronic No. of Chronic
ConditionsConditions
% Medicare% Medicare
BeneficiariesBeneficiaries
% Medicare % Medicare
ExpendituresExpenditures
00 24.524.5 3.53.5
11 22.522.5 8.28.2
22 20.620.6 14.314.322 20.620.6 14.314.3
33 13.813.8 15.615.6
>4>4 18.618.6 58.458.4
Overall age groupOverall age group 100.0100.0 100100
Note: Individuals with 0 conditions accounted for 25% of population but 3.5% of
costs. Individuals with >2 conditions accounted for 53% of population but 88% of costs.
Models for Re-engineering Chronic Care
Chronic Care Model – Practices organized to enable team care, case management, patient self-management, and clinical use of IT
Hospital at Home - Program to treat acute illnesses at home with RN & MD monitoring
Palliative Care – Programs designed to improve pain and symptom control, to provide psycho-social support, and to symptom control, to provide psycho-social support, and to help with goals of care
Acute Care for the Elderly – Redesigned hospital units with protocols to improve elder care
Hospital Elder Life Program – Hospital protocols to enhance orientation, feeding, mobilization, sleep, & adaptation to sensory deficits
Transition Services – Programs developed to link hospital and home follow up
Program & Characteristics Impact on Value
Hospital at Home: ED identification of patients for hospital level care at home with MD daily visits and 24 hour nursing.
Quality: Patients treated at home had shorter periods of acute service use (3.2 vs. 4.9 days) and equivalent or better quality outcomes. Cost: Mean costs $2399 or 32% lower per case ($489/day lower).
Hospital Elder Life Program (HELP): team plus inpatient intervention protocols to prevent delirium.
Quality: Program prevents delirium in up to 40% of cases. Cost: Savings of $831/patient ($2,500 per avoided case of delirium).
Palliative Care: inpatient consult services that improve pain, symptom
Quality:Cost: Decedents with LOS of >15 days receiving palliative care
Examples of Model Programs and Estimates of Impact
services that improve pain, symptom management, and communication.
Cost: Decedents with LOS of >15 days receiving palliative care consultation in one hospital had a 1.9 day LOS reduction (compared to matched controls). For decedents with LOS of >21 days, LOS decreased 5.1 days.
The Care Transitions Program: 4 week support by Transition Coach pre and post discharge to support self management.
Quality: 30% reduction in readmission rates within 30 days (8.3 vs.11.9%)Overall impact estimated as 47% reduction in readmissions as compared to national average rates for Medicare (from 19% to 10%)
What do Chronic Care Model, ACE, Hospital at Home,
Palliative Care, Hospital Elder Life Program, and
Transition Services have in common?
1. Evidence of improvements in care2. Evidence of possible cost savings3. No formal reimbursement mechanism
Current Reimbursement System Provides the Wrong Incentives
Current incentives drive volume and intensity of services
Hospital payments create financial incentives for hospitals to invest mainly in relatively hospitals to invest mainly in relatively profitable surgical conditions
Need incentives that will capitalize on potential of EHR, comparative effectiveness, and chronic care innovations
Keep some patients with
Move Inpatients Through the
System Safely and Efficiently:
ACE/HELP
NICHE
Palliative CarePrevent Readmissions:
Care Transition Keep some patients with
acute illness out of the
hospital :
Hospital at Home
Care Transition
Program
Provide patient-centered,
coordinated care:
PCMH
(e.g. GRACE)
Need Payment Model Not Driven by More Hospitalizations and Procedures
Pay more for non-procedure care, transition services and care coordination
Pay for PerformancePay for Performance
Accountable Care Organizations
Bundled payment with bonuses for performance
Shared accountability for resource use with shared savings
Conclusions
Improvement in longevity has been striking and sustained over a century
Longevity improvement is likely due to a combination of factors (prosperity, education, biomedical advances, and factors (prosperity, education, biomedical advances, and improved access to care)
To sustain longevity, we need to continue investment in science, education, and in access to care
Improvement in longevity also require societal responses to accommodate long life
